Chapter Thirteen

February

I was still the junior resident on Dr. Romero’s service when I met Susan Schenk. Susan was a forty-three-year-old kindergarten teacher from Winona, Minnesota, who came to our clinic one Monday morning complaining of left hip pain. The pain had started insidiously about a month earlier. A well-conditioned athlete who enjoyed her daily three-mile run, Susan had been forced to stop running because of the pain.

“Do you limp?” I asked.

She hesitated. “Well, my husband thinks I do.”

“Do you have any pain at night?”

Susan nodded. “Yes,” she said. “In fact, for the past week it’s been waking me up almost every night. That’s why I figured I’d better get over here and let you guys take a look.”

I was becoming increasingly concerned. “Do you have any history of cancer?” I asked, trying to keep my voice casual.

“Nope, healthy as a horse,” she answered.

“How about your parents or relatives—any cancer or anything there?”

“Well, my mother died of breast cancer a few years ago. But she was seventy-eight.”

Susan said her general health was good. Yes, she’d been losing a little weight, but she attributed that to her running. She had also been feeling a little tired lately, but she said she wasn’t concerned about that. “It’s just this stupid hip,” she said. “I’m sure it’s nothing, but it won’t go away.”

Except for a little tenderness over the side of her hip, Susan’s exam was normal. I sent her for a hip X-ray and went on to our next patient. Susan’s X-rays were back two hours later. I stood outside her exam room, pulled the films out of the jacket, and held them up to the light. I winced and thought, Oh, no. Susan had a large lytic lesion in the subtrochanteric area of the femur.

 

I brought the films over to Dr. Romero. He stared at them for several seconds, then looked up at me. We both knew that the X-ray almost certainly indicated metastatic cancer, probably from the breast.

The two of us, somber-faced, went in to talk to Susan. Dr. Romero went through the same sort of history and physical as I had. He then told Susan the X-ray indicated a problem.

“Good!” she said with a laugh. “I was beginning to think it was all in my head.”

When neither of us smiled, she must have sensed something was wrong.

“What is it?” she asked. “What’s wrong? It’s not arthritis, is it?”

“No, Mrs. Schenk, it’s not arthritis.”

There was another uncomfortable silence. Dr. Romero finally said, “We can’t be sure at this point exactly what it is, but we need to run a few more tests.”

Susan looked anxiously first at me, then at Dr. Romero, searching our faces for more information. She was starting to understand. “It’s something bad, isn’t it?”

Dr. Romero paused slightly and said, “It might be.”

Her shoulders sagged, her head dropped on her chest, and she put her right hand over her eyes. “Oh, God,” she whispered.

Dr. Romero took her hand and told her no definite diagnosis could be made yet. He said he was sorry to upset her, and sorrier still that it would be two days before the test results would be back. He offered to call her husband and talk to him.

Susan shook her head. “No,” she said, “I’d rather not worry him.”

I wrote out orders for a bone scan and several blood tests, then told Susan we would see her in two days to go over the test results with her. “In the meantime,” I said, “you need to start using crutches. Your hip bone is weak and could break if you put too much pressure on it.”

“It could break? Just from walking on it?” This was a woman who, just a few weeks ago, had been running three miles a day.

“Well, we don’t want to take any chances,” I told her.

 

Two days later while Susan and her husband were waiting in one of the exam rooms, Dr. Romero and I were down in radiology looking at the bone scan. Susan’s entire skeleton was riddled with cancer. We could tell this wasn’t primary bone cancer. It had spread from somewhere else.

“Could be thyroid or kidney,” Dr. Romero said, “but the vast majority of cancers that present like this are from the breast.”

I wondered how he was going to tell Susan and her husband. Long gone were the days when doctors would hide things like this from their patients. And yet we both wished there were some way we could spare them some of the terror and shock.

“I try to break it to them slowly,” Dr. Romero said as we rode the elevator back to the fourteenth floor. “People can’t process too much bad news all at once. They stop hearing what you say.” He had obviously been through this many times before. He sighed and went on. “We already prepared Mrs. Schenk a little. She knows the tests might show a problem.”

As we entered the exam room, Susan and her husband jumped to their feet and looked at us apprehensively. After brief introductions, Dr. Romero got right to the point. “I know you are anxious about the results of your tests,” he began. “The bone scan confirmed that the spot we saw in your left hip appears to be a malignancy. That malignancy probably started somewhere else and spread, not only to your hip, but to a number of other bones as well.”

With each pronouncement, Susan and her husband clung more desperately to each other. Relentlessly, Dr. Romero went on. “In addition, your blood tests indicate that you are anemic and that your liver may also be involved. All these things will have to be investigated.”

The Schenks sat there in stunned silence for several seconds until Mr. Schenk said quietly, “What does all this mean?”

Although he would never have articulated his question this way, what he really meant was Is my wife going to die? And although we would never have articulated our response this way, the answer was Yes. I knew Dr. Romero wouldn’t be that blunt. Not here. Not now. They needed a little time to absorb all this.

“It means your wife is a very sick woman,” Dr. Romero said. “It means she is going to need a lot of help and a lot of treatment.”

“So it’s…cancer?” Susan asked.

“Yes, Mrs. Schenk, it’s cancer.”

 

We admitted Susan to the hospital that afternoon. A CT scan of her abdomen showed widespread metastatic disease. The oncologists examined her breast and found a large lump. Two days later, she had a radical mastectomy. Ten out of ten lymph nodes in her axilla were positive for cancer.

“Things are about as bad as they could be,” the oncologist told us. “Even with chemotherapy and radiation I doubt she will live six months.”

Things were happening so fast Susan could hardly take it all in. Within the space of three days she had gone from thinking she was a healthy woman with a sore hip to a condemned woman who was told she would be dead before the end of summer.

And to make matters worse, there was still the question of what to do about her hip.

“The cancer has eaten away some of the bone in your hip,” Dr. Romero told her. “We can kill the cancer with radiation, but that will still leave a large, weak spot that could fracture.”

“What can be done?” Susan asked.

“We could do what’s called a prophylactic pinning. That means we wouldn’t wait for the bone to break. We would go in now and put a plate and screws in to prevent the bone from breaking.”

“Do you know for sure that it will break if I don’t have the surgery?”

“No, Mrs. Schenk, we don’t. But if we do nothing and the bone breaks, the surgery is much more difficult to perform.”

Susan nodded and said nothing. She turned her head and looked out the window.

“Take some time to think about it,” Dr. Romero said. “Talk to your husband. If you have any more questions you can talk to me or Dr. Collins anytime.”

Later that afternoon, when I was making rounds by myself, Susan asked if she could talk to me about the operation. “What do you think I should do?” she asked.

The indications for surgery were clear: a one-inch lesion occupying greater than fifty percent of the diameter of the bone warrants prophylactic fixation. Period. The risk of fracture is too great otherwise. I explained that to her.

She nodded patiently. “Yes, but do you think I should have the operation?”

There was no doubt. The literature was clear. I started to say, “Of course, absolutely,” but all that came out was, “I…”

Susan looked up at me from her bed, waiting for an answer. The answer should have been easy, but I hesitated. She had just undergone a radical mastectomy and an axillary node dissection. The general surgeons had opened her belly and closed it right back up when they found the disease was too widespread to operate on. She was constantly sick from the chemotherapy. And now we were proposing to do another major, painful operation for a problem that might occur?

“I doubt she will live six months,” the oncologist had said.

Did we really need to add to her misery with another operation? The literature was clear, but the literature was only about her femur. Yes, it would be good for her femur to be prophylactically fixed, but that didn’t mean it was good for Susan overall. Another operation meant more pain, more weakness, more debilitation. That was taking a lot from a woman with very little left to give.

But I was only a junior resident. Shouldn’t I just stick to the party line and shut up?

“Susan,” I said gently. “Do you realize that without the operation your hip may break, and if it does it will be a lot harder to fix than it is now?”

“Please,” she said. “I can’t take any more of this. I don’t want any more operations. I just want to go home.”

I reached over and laid my hand on the top of hers. “So would I.”

 

Susan declined the surgery and left the hospital two days later. For weeks I was terrified every time my beeper went off. I was afraid that it would be the ER calling to say Susan had fractured her hip. It would be all my fault. But the call never came.

Susan died at home on Easter Sunday. The day before she died, her hip broke as her sister rolled her over to change her sheets. Susan was in a coma by then and never knew it.